A 9-month-old female infant presents to the immunisation clinic. Her immunisation card shows she received BCG at birth, DPT (1st dose) at 6 weeks, and Rotavirus (1st dose) at 6 weeks. She has not received any further vaccinations. The mother reports she was unwell with fever and cough for 2 weeks, 1 month ago, and was diagnosed with tuberculosis. She is now on anti-TB therapy for 3 weeks. According to the National Immunisation Schedule, which vaccine should be given TODAY at this 9-month visit?

Explanation

## Immunisation Schedule at 9 Months — Catch-Up and TB Contact Management ### Clinical Scenario Analysis - **Child's age:** 9 months - **Maternal TB status:** Recently diagnosed (3 weeks into therapy) - **Child's TB exposure:** Household contact with TB patient - **Immunisation status:** Behind schedule (missed DPT 2, Rotavirus 2, PCV, and Measles) ### National Immunisation Schedule — 9-Month Milestones | Age | Vaccine | Notes | |-----|---------|-------| | 6 weeks | DPT-1, Rotavirus-1, IPV-1, PCV-1 | Primary series begins | | 10 weeks | DPT-2, Rotavirus-2, IPV-2, PCV-2 | — | | 14 weeks | DPT-3, Rotavirus-3, IPV-3, PCV-3 | — | | **9-10 months** | **Measles/MR** | **Single dose; can be given from 9 months** | | 12-15 months | DPT Booster-1, IPV Booster, PCV Booster | — | ### Key Point: **At 9 months, the child is due for Measles/MR vaccine.** This is a critical milestone vaccine that should NOT be delayed. The child is also overdue for DPT-2, Rotavirus-2, and PCV doses. ### TB Contact Management in Vaccinated Child **The child has already received BCG at birth.** Current guidelines state: 1. **BCG-vaccinated children exposed to TB:** Do NOT require isoniazid prophylaxis if they have received BCG and are asymptomatic. 2. **Vaccinations should NOT be deferred** solely because of TB contact in the household, provided the child is asymptomatic and has no signs of active TB disease. 3. **TB screening:** A tuberculin skin test (TST) or IGRA may be done, but negative results do not contraindicate vaccination. 4. **If TST positive or active TB suspected:** Refer for TB evaluation; defer non-urgent vaccines until TB is ruled out. ### High-Yield: **Measles/MR at 9 months is a non-negotiable milestone vaccine.** It should be given even in TB-exposed contacts if the child is asymptomatic and has no signs of active TB. Delaying Measles vaccine increases the risk of vaccine-preventable disease. ### Why DPT-2 and PCV Should Also Be Given Today 1. **DPT-2 is overdue** (should have been given at 10 weeks; now at 9 months). 2. **PCV-1 was not given at 6 weeks** (missed); PCV series should be completed. 3. **Rotavirus-2 was missed** (should have been at 10 weeks); can still be given if <6 months since Rotavirus-1 (acceptable window up to 6 months between doses). 4. **IPV-1 was not documented** (should have been at 6 weeks); IPV series should be initiated. ### Clinical Pearl: In TB-exposed but asymptomatic BCG-vaccinated children, **vaccination schedules should proceed as normal.** The presence of a TB contact in the household is NOT a contraindication to routine immunisation. However, if the child develops symptoms suggestive of TB (fever, weight loss, lymphadenopathy), TB evaluation takes priority. ### Mnemonic: **9-MONTH CATCH-UP (in order of priority):** - **9 months = Measles/MR** (single most important at this age) - **Overdue DPT-2, PCV-1, Rotavirus-2, IPV-1** (complete primary series) - **TB contact ≠ vaccine deferral** (if asymptomatic and BCG-vaccinated) ### Why Measles/MR is Prioritized Measles is a highly contagious disease (R₀ = 12–18) with significant morbidity and mortality in unvaccinated children. The 9-month Measles/MR vaccine is a critical milestone that should not be delayed. Delaying this vaccine for TB investigation (if the child is asymptomatic) exposes the child to unnecessary risk.